食管癌切除术中不同方式处理胸导管预防术后乳糜胸研究的Meta分析

Comparison of Different Surgical Thoracic Duct Management on Prevention of Postoperative Chylothorax for Esophagectomy:A Meta-analysis

目的探讨食管癌切除术中不同的胸导管处理方式预防术后乳糜胸的效果及对患者术后转归的影响。方法计算机检索Pub Med、The Cochrane Library(2016年4期)、CBM、CNKI、VIP及Wan Fang Data,搜集关于食管癌术中不同方式处理胸导管预防乳糜胸的随机对照试验(RCT)、队列研究及病例-对照研究,检索时限均为建库至2016年5月。由2名研究者独立进行文献筛、资料提取并评价纳入研究的质量,然后采用Rev Man 5.2软件进行Meta分析。结果共纳入23篇文献,包括4个RCT、4个队列研究和15个病例-对照研究。Meta分析结果显示:(1)食管癌术中胸导管结扎组的术后乳糜胸发生率明显低于未结扎组[RCT:OR=0.20,95%CI(0.09,0.47),P=0.000 2;队列/病例-对照:OR=0.20,95%CI(0.14,0.28),P<0.000 01]。(2)食管癌切除术中,结扎与不结扎胸导管在患者围手术期死亡率、其余并发症发生率及术后第2、3、5年生存率上无差别(P均>0.05);(3)结扎组并发乳糜胸的患者再手术率明显低于未结扎组[RCT:OR=0.13,95%CI(0.03,0.59),P=0.008;队列/病例-对照:OR=0.18,95%CI(0.11,0.32),P<0.000 01],其保守治疗治愈率高于未结扎组[OR=0.14,95%CI(0.04,0.54),P=0.004]。(4)胸导管集束结扎组术后乳糜胸发生率明显低于胸导管单根结扎组[OR=3.67,95%CI(1.43,9.43),P=0.007)]。结论食管癌切除术中预防性结扎胸导管可有效降低术后乳糜胸发生率,并有利于降低并发乳糜胸患者的再手术率,胸导管集束整块结扎预防乳糜胸效果优于单根胸导管游离结扎。

Objectives To compare the clinical efficacy of different surgical thoracic duct management on prevention of postoperative chylothorax and its impact on the outcome of the patients. Methods We searched the electronic databases including PubMed, The Cochrane Library （Issue 4, 2016）, Web of Science, CBM, CNKI, VIP and WanFang Data to collect randomized controlled trials （RCTs）, cohort studies and case-control studies related to the comparison of different surgical thoracic duct management during esophagectomy on prevention of postoperative chylothorax from inception to May 2016. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then RevMan 5.2 software was used for meta-analysis. Results Twenty-three trials were induded, involving four RCTs, four cohort studies and 15 case-control studies, The results of meta-analysis indicated： （1） Prophylactic thoracic duct ligation group had lower incidence of postoperative chylothorax compared with non thoracoic duct ligation group （RCT： OR=0.20, 95%CI 0.09 to 0.47, P=O.O00 02; Co/CC： OR=0,20, 95%CI 0.14 to 0.28, P〈O.O00 01）; （2） There were no significant differences between the two groups in the respect of mortality, morbidity and the 2-year, 3-year, 5-year survival rates （all P values 〉0.05）; （3） Prophylactic thoracic duct ligation could reduce the reoperation rate of chylothorax complicating esophageal cancer patients （RCT： OR=0.17, 95%CI 0.10 to 0.28, P〈0.000 01; Co/CC： OR--0.18, 95%CI to 0.11 to 0.32, P〈O.O00 01）, and increase the cure rate of expectant treatment on them （OR=0.25, 95%CI 0.11 to 0.56, P=0.000 8）; （4） En bloc thoracic duct ligation group had a lower incidence of postoperative chylothorax compared with single thoracic duct ligation group （OR=3.67, 95%CI 1.43 to 9.43, P=0.007）. Conclusion Prophylactic thoracic duct ligation during esophagectomy could effectively reduce the incidence of postoperative chylothorax and is good for reducing the reoperation rate of chylothorax complicating esophageal cancer patients. En bloc thoracic duct ligation has a better efficacy on prevention of postoperative chylothorax compared with single thoracic duct ligation.